Citation Nr: 20027896 Decision Date: 04/21/20 Archive Date: 04/21/20 DOCKET NO. 17-07 744 DATE: April 21, 2020 ORDER New and material evidence having been received, the claim of entitlement to service connection for a respiratory disability is reopened. Entitlement to service connection for a heart disability is denied. Entitlement to service connection for a psychosis or mental illness for the purposes of treatment only, pursuant to 38 U.S.C. § 1702, is denied. Entitlement to special monthly pension (SMP) based on the need for aid and attendance or housebound status is denied. REMANDED Entitlement to service connection for an acquired psychiatric disability is remanded. Entitlement to service connection for thoracolumbar spine disability is remanded. Entitlement to service connection for a neurological disability of the bilateral lower extremities is remanded. Entitlement to service connection for a gastrointestinal disability is remanded. Entitlement to service connection for a respiratory disability is remanded. Entitlement to service connection for a skin disability is remanded. Entitlement to service connection for hepatitis C is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. In a July 1988 rating decision, the AOJ denied service connection for a respiratory disability; the Veteran did not appeal that decision, and new and material evidence was not actually or constructively received within the one year appeal period. 2. Evidence added to the record more than one year since the July 1988 rating decision relates to unestablished facts and raise a reasonable possibility of substantiating the claim for service connection for a respiratory disability. 3. The Veteran does not have a current heart disability. 4. The Veteran did not develop an active psychosis in service or within two years of service separation. 5. The Veteran served on active duty from April 1972 to November 1973; although the Veteran requires some assistance, his conditions in and of themselves do not result in the need for the regular aid and attendance of another person demonstrated by an inability to care for most of his daily personal needs, protect himself from the hazards and dangers of his daily environment, or an inability to attend to the wants of nature. CONCLUSIONS OF LAW 1. The July 1988 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence having been received, the criteria for reopening the claim of entitlement to service connection for a respiratory disability are met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for service connection for a heart disability are not met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for the purpose of establishing eligibility for treatment of a psychosis under 38 U.S.C. § 1702 are not met. 38 U.S.C. § 1702; 38 C.F.R. § 3.384. 5. The criteria for entitlement to SMP based on the need for regular aid and attendance or by reason of being housebound are not met. 38 U.S.C. §§ 1502, 1521, 5107; 38 C.F.R. §§ 3.102, 3.351, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from April 1972 to November 1973. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from a December 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office. The Veteran testified before a Decision Review Officer (DRO) at a March 2016 DRO hearing, and before the undersigned at an October 2019 Board hearing. The Veteran’s claims for service connection for PTSD and anxiety, sciatica, upper and lower gastrointestinal disabilities, and upper respiratory pneumonia have been broadened and recharacterized as reflected on the title page. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1. New and material evidence having been received, the claim of entitlement to service connection for a respiratory disability is reopened. In order to reopen a claim which has been denied by a final decision, the claimant must present new and material evidence. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The language of 38 C.F.R. § 3.156(a) creates a low threshold for finding new and material evidence, and views the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” Evidence “raises a reasonable possibility of substantiating the claim,” if it would trigger VA’s duty to provide an examination in adjudicating a non-final claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). The claim of entitlement to service connection for a respiratory disability, claimed as pneumonia with bronchitis, was initially denied in a July 1988 rating decision based on lack of evidence of a current chronic pulmonary condition. Because the Veteran did not appeal the July 1988 rating decision and VA did not actually or constructively receive new and material evidence prior to expiration of the appeal period, the July 1988 rating decision became final. 38 U.S.C. § 7105(b), (c); 38 C.F.R. §§ 3.156(b), 3.160(d), 20.201, 20.302, 20.1103. Evidence added to the record more than one year the prior final denial includes December 2011 VA respiratory examination report, which reflects a diagnosis of an upper respiratory infection. Thus, the petition to reopen the previously denied claim for service connection for a respiratory condition is granted. 2. Entitlement to service connection for a heart disability is denied. A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C. § 1110. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran filed a September 2009 claim for service connection for a cardiology problem. See September 2009 VA Form 21-526. In the absence of proof of a present disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The competent evidence of record does not demonstrate a current heart disability diagnosis at any point just prior to or during the appeal period. The Board acknowledges that at his October 2019 Board hearing, the Veteran testified that while in service he was told he had heart problems and that findings showed he had a massive stroke in service. See October 2019 Board Hearing Tr. at 13-14. However, the Veteran’s service treatment records (STRs) do not support that the Veteran has had heart treatment, diagnoses, or complaints in service, and the Board affords this more contemporaneous evidence more probative value. Specifically, a February 1972 report of medical examination at enlistment and an October 1973 report of medical examination indicated the Veteran had normal heart and vascular system findings upon clinical evaluation. In a November 1973 statement of medical condition, the Veteran reported there has been no change in his medical condition. Further, post-service treatment records do not support that the Veteran has a current heart disability. In this regard, the Board notes that May 2003 radiographic imaging of the Veteran’s chest revealed the heart size and pulmonary vascularity were within normal limits. Significantly, the Veteran testified that he is not currently receiving any medical treatment for a heart problem. See October 2019 Board Hearing Tr. at 14. Moreover, while Veteran is competent to report symptomatology such as chest pain, he is not competent to diagnose a heart disability because he does not possess the requisite medical training or expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, the Board finds that the Veteran does not have a current heart disability, there is no doubt to be resolved in his favor, and his claim fails on this basis alone. The Board acknowledges that the Veteran has not been afforded a VA examination for this claim. However, given the evidence does not support a current disability, a VA examination is not warranted. Indeed, the available records and medical evidence is sufficient to make an adequate determination as to this claim. 38 C.F.R. § 3.159(c)(4). 3. Entitlement to service connection for a psychosis or mental illness for the purposes of treatment only, pursuant to 38 U.S.C. § 1702, is denied. Under 38 U.S.C. § 1702(a), any veteran of World War II, the Korean conflict, the Vietnam era, or the Persian Gulf War who developed an active psychosis (1) within two years after discharge or release from the active military, naval, or air service, and (2) before July 26, 1949, in the case of a veteran of World War II, before February 1, 1957, in the case of a veteran of the Korean conflict, before May 8, 1977, in the case of a Vietnam era veteran, or before the end of the two-year period beginning on the last day of the Persian Gulf War, in the case of a veteran of the Persian Gulf War, shall be deemed to have incurred such disability in the active military, naval, or air service for the purposes of receiving VA medical treatment. Under 38 C.F.R. § 3.384, the term psychosis is defined so as to include brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder not otherwise specified, schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder, and substance-induced psychotic disorder. The Veteran served on active duty from April 1972 to November 1973, during the Vietnam era. He has not provided evidence of a psychosis, to include a diagnosis of psychosis or symptoms thereof, during active service or within two years of service separation. The Board acknowledges that an October 1973 report of medical history revealed the Veteran was depressed about the Army, which he is competent to report; however, clinical evaluation at that time revealed normal psychiatric findings, and the Veteran’s post-service treatment records do not show evidence of a diagnosis of psychosis or treatment for symptoms of psychosis within two years of discharge or release from active duty service. Thus, the in-service report of depression is not reflective of any psychosis as outlined in 38 C.F.R. § 3.384. In this regard, at his October 2019 Board hearing, the Veteran testified that he did not seek any treatment right after service. See October 2019 Board Hearing Tr. at 23. Accordingly, as the preponderance of the evidence is against the claim, eligibility to treatment pursuant to 38 U.S.C. § 1702 is not warranted. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). In light of the above, the preponderance of the evidence is against the claim. The benefit of the doubt doctrine is not for application and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Entitlement to SMP based on the need for aid and attendance or housebound status is denied. SMP at the aid and attendance rate is payable when a veteran exhibits helplessness or being so nearly helpless as to require the regular aid and attendance of another person. A claimant will be considered in need of regular aid and attendance if he or she: (1) is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; (2) is a patient in a nursing home because of mental or physical incapacity; or (3) establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a). 38 U.S.C. § 1502(b); 38 C.F.R. § 3.351(b), (c). The following will be accorded consideration in determining a factual need for regular aid and attendance: inability of a claimant to dress or undress himself or herself, or to keep himself or herself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of a claimant to feed himself or herself through loss of coordination of the upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect a claimant from hazards or dangers incident to his or her daily environment. “Bedridden” will be a proper basis for the determination. For the purpose of this paragraph bedridden will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. It is not required that all of the disabling conditions enumerated in this paragraph be found to exist before a favorable rating may be made. The particular personal functions which the claimant is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the claimant is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the claimant is so helpless, as to be in need of regular aid and attendance, will not be based solely upon an opinion that the claimant’s condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. 38 C.F.R. § 3.352(a); see also Turco v. Brown, 9 Vet. App. 222, 224 (1996) (providing that eligibility by reason of regular need for aid and attendance requires that at least one of the factors set forth in VA regulation is met, but not all). If a veteran does not qualify for increased benefits at the aid and attendance rate, SMP at the housebound rate is payable if he or she has a single permanent disability evaluated as 100 percent disabling (not including ratings based upon unemployability under 38 C.F.R. § 4.17, and, in addition: (1) has additional disability or disabilities independently ratable at 60 percent or more, separate and distinct from the permanent disability evaluated as 100 percent disabling and involving different anatomical segments or bodily systems; or (2) is “permanently housebound” by reason of a disability or disabilities. 38 U.S.C. § 1521(e); 38 C.F.R. § 3.351(d). The requirement of being permanently housebound is met when a claimant is substantially confined to his or her house (ward or clinical areas, if institutionalized) or immediate premises due to disability or disabilities, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C. § 1502(c); 38 C.F.R. § 3.351 (d)(2). Substantially confined means the inability to leave the house except in instances of seeking medical treatment. Howell v. Nicholson, 19 Vet. App. 535, 540 (2006). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the criteria for SMP based on the need for regular aid and attendance or by reason of being housebound have not been met. The Veteran has not been granted nonservice-connected pension. Further, the Veteran does not have any service-connected disability. The record does not show, nor does he contend, that he is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or that he has concentric contraction of the visual field to 5 degrees or less. The record also does not show, nor does he contend, that he has been a patient in a nursing home because of mental or physical incapacity. He has not argued that he is unable dress or undress himself, feed himself, keep himself ordinarily clean and presentable, or attend to the wants of nature. He also has not argued that he needs adjustment of any special prosthetic or orthopedic appliances which cannot be done without aid or that he requires care or assistance on a regular basis to protect himself from hazards or dangers incident to his daily environment. Significantly, at his October 2019 Board hearing, the Veteran testified that he currently does not need somebody to take care of him for his daily routine activities. See October 2019 Board Hearing Tr. at 22-23. In sum, despite the Veteran’s reports that he has needed some assistance when his back goes out, he has not been shown to be in need of regular aid and attendance to meet the requirement for SMP. Moreover, he has conceded that he does not need somebody to take care of him for his routine daily activity. See id. In reaching this decision, the Board notes that it has considered the possible functional effects from the Veteran’s physical and mental conditions, but still finds that the required criteria have not been met. Therefore, the evidence weighs against the claim. As such, the benefit-of-the-doubt rule does not apply and the appeal is denied. REASONS FOR REMAND 5. Entitlement to service connection for an acquired psychiatric disability is remanded. The Veteran filed a September 2009 claim for service connection for anxiety and PTSD. See September 2009 VA Form 21-526. The Veteran’s VA treatment records have documented anxiety as an active problem throughout the record. See August 2008 VA treatment records STRs include an October 1973 report of medical history, which revealed the Veteran was depressed about the Army. Further, at his March 2016 DRO hearing, the Veteran reported being stabbed in service. At his October 2019 Board hearing, the Veteran testified that while in service he experienced stressor events including: that he witnessed somebody getting shot down on the rifle range; a guy getting blown up on the grenade range; an unlisted man put on a wall locker and thrown out of a third-story window; and an incident where a guy grabbed an antenna on the barracks and swing out of a third-story window, the line snapped and he hit the ground and broke his legs and injured himself. See October 2019 Board Hearing Tr. at 3. To date, it does not appear that appropriate development has been conducted by the AOJ to attempt to verify the Veteran’s stressor events. Moreover, given the in-service notation of depression, and current notation of anxiety, the Board finds that remand for VA examination using the applicable DSM-5 criteria is warranted. 6. Entitlement to service connection for thoracolumbar spine disability is remanded. August 2007 radiographic imaging of the Veteran’s lumbar spine revealed multilevel degenerative disc disease from L3/4 through L5/S1. At his October 2019 Board hearing, the Veteran testified that he sustained injury from running and going through obstacles. See October 2019 Board Hearing Tr. at 6. He testified that the first time that he felt he had an injury to his back was during basic training and he was given whirlpool treatments. Id. Through his representative, the Veteran testified that while in service he got a congeal bone fragment in his back that sticks in his spine. Id. He testified that since his injury in service, his back has continued to bother him to present. Id. at 8. To date, the Veteran has not been afforded a VA back examination and should be scheduled on remand. 7. Entitlement to service connection for a neurological disability of the bilateral lower extremities is remanded. At his October 2019 Board hearing, the Veteran testified that he was diagnosed with sciatica in basic training and he was told that he had spondylolisthesis since birth. Id at 6-7. He testified that his sciatica is part of his back disability and they both stemmed from basic training in service. Id. at 8. As the claim for service connection for back disability is remanded for VA examination, the claim for sciatica is also remanded as inextricably intertwined with the back claim. 8. Entitlement to service connection for a gastrointestinal disability is remanded. VA treatment records document esophageal reflux disease as an active problem throughout the record. See July 2008 VA internal medicine note. At his October 2019 Board hearing, the Veteran testified that he received treatment for his upper and lower gastrointestinal disorder during service and got pills for it. See October 2019 Board Hearing Tr. at 9. He testified that his stomach was bloated with gas and sharp pain and he started bleeding. The Veteran testified that he has had reflux issues in his stomach since service. Id. To date, the Veteran has not been afforded a VA examination for his claimed gastrointestinal disability and should be scheduled on remand.   9. Entitlement to service connection for a respiratory disability is remanded. The Veteran has a currently diagnosed upper respiratory infection, unspecified sites. See December 2011 VA examination report. Further, a May 2003 chest x-ray revealed chronic obstructive pulmonary disease (COPD) with mild upper and lower fibrosis in the upper and lower lungs. STRs include an October 1973 report of medical history, which revealed the Veteran had occasional upper respiratory infections. At his October 2019 Board hearing, the Veteran testified that he had respiratory problems, such as upper respiratory infection, pneumonia, and bronchitis in service for the first time in basic training when he was being questioned by his sergeant in the gas chamber for approximately half an hour without a gas mask. See October 2019 Board Hearing Tr. at 12. He testified that from there, he went to the hospital for an infection and scarring on his lungs. Id. He testified that within a couple of months, it was winter, and he got transferred to Germany, where he got diagnosed with pneumonia after being stuck in the snow for 16 hours. Id. He testified that every year around October and November he has a respiratory infection and pneumonia to present. Id. Further, in October 2010 the Veteran reported that he was exposed to mustard gas while stationed in Germany related to his job of transporting and retrieving old war heads from bunkers that contained mustard gas and leaked. See October 2010 VA 21-0820 report of general information and October 2010 radiation risk activity information sheet. The December 2011 VA respiratory examiner diagnosed the Veteran with upper respiratory, unspecified sites disability and opined that the Veteran’s respiratory condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. See December 2011 VA examination report. The examiner explained that upper respiratory infections or the common cold are usually caused by a viral infection in the noise, sinuses, and/or throat, that they can be caused by more than 200 different types of viruses, and that someone is more likely to develop an upper respiratory infection if they are a smoker, experiencing mental and/or physical stress, or getting inadequate sleep. The Veteran has a history of tobacco use. However, the Board notes that the VA examiner did not address the May 2003 chest x-ray, which revealed chronic obstructive pulmonary disease with mild upper and lower fibrosis in the upper and lower lungs. Thus, remand for VA addendum opinion is warranted. 10. Entitlement to service connection for a skin disability is remanded. At his October 2019 Board hearing, the Veteran testified that while in service the hair was falling off his legs and nowhere else because he was in a bunker with leaking ammunitions that had biological and atomical radiation. See October 2019 Board Hearing Tr. at 14-15. He testified that he was diagnosed with vitiligo. Id. at 16. Further, in October 2010 the Veteran reported that he was exposed to mustard gas while stationed in Germany related to his job of transporting and retrieving old war heads from bunkers that contained mustard gas and leaked. See October 2010 VA 21-0820 report of general information. To date, the Veteran has not been afforded a VA skin examination and should be scheduled on remand. 11. Entitlement to service connection for hepatitis C is remanded. VA treatment records document chronic hepatitis C as an active problem throughout the record. See July 2008 VA internal medicine note. At his October 2019 Board hearing, the Veteran testified that he was diagnosed with hepatitis C in service. See October 2019 Board Hearing Tr.t at 18. He testified that he was tested and diagnosed with hepatitis C in service while he was in Germany. Id. at 19. He also testified that he was given 21 shots in service by air gun. Id. at 11-12. At his March 2016 DRO hearing, the Veteran was told VA would send him a hepatis questionnaire; however, to date it does not appear a questionnaire was sent to or completed by the Veteran. As such, remand for development is needed. 12. Entitlement to a TDIU is remanded. In his November 2010 claim for TDIU, the Veteran reported that he was too disabled to work due to major organ degeneration and degenerative back, which caused him to cease full time work in November 1989. See November 2010 VA Form 21-8940. Further, at his October 2019 Board hearing, the Veteran testified that his degenerative stomach and degenerative back disease prevent him from securing or following substantially gainful occupation. See October 2019 Board Hearing Tr. at 20. Having remanded the Veteran’s claims for service connection for thoracolumbar spine disability and gastrointestinal disability; the Veteran’s TDIU claim is also remanded as it is inextricably intertwined with the back and gastrointestinal disability claims. Any outstanding records should also be secured. The matters are REMANDED for the following action: 1. Obtain outstanding relevant VA treatment records and associate them with the claims file.’ 2. With any necessary assistance from the Veteran, obtain any outstanding relevant private treatment records. 3. Attempt to verify whether while in service the Veteran: (1) was stabbed; (2) witnessed somebody getting shot down on the rifle range; (3) witnessed a guy getting blown up on the grenade range; (4) witnessed an unlisted man put on a wall locker and thrown out of a third-story window; and/or (5) witnessed an incident where a guy grabbed an antenna on the barracks and swing out of a third-story window, the line snapped and he hit the ground and broke his legs and injured himself. The AOJ must prepare a summary of the stressors or in-service injury/events that it has determined are established by the record. 4. Provide the Veteran with a hepatitis C risk factor questionnaire and inform him that he must complete and return the form. Notify him that failure to do so may adversely affect his claim for service connection for hepatitis C. 5. Then schedule the Veteran for a VA psychiatric examination. The Veteran’s claims file, including a copy of this remand, must be made available to and reviewed by the examiner. The examiner should address the following: (a) Identify all psychiatric disabilities present, to include whether the Veteran has, anxiety, depression, and/or PTSD. The examiner should reconcile this with any diagnoses of record and provide an explanation. (b) If PTSD is diagnosed, the examiner should specifically determine whether it is at least as likely as not (a 50 percent or greater possibility) that the Veteran’s PTSD is related to his military service. If a diagnosis of PTSD is deemed appropriate, the examiner must explain how the diagnostic criteria of the DSM-5 are met, to include identification of the specific stressor(s) underlying the diagnosis, and comment upon the link between the current symptomatology and the stressors). The examiner must state whether the claimed stressor(s) is adequate to support a diagnosis of PTSD. If a diagnosis of PTSD is not deemed appropriate, the examiner must specifically explain this finding in light of any previous diagnoses of PTSD of record. (c) For each psychiatric diagnosis provided other than PTSD, the examiner should opine as to whether it is at least as likely as not related to service or any incident in service, to include his report of depression at service separation. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. If the examiner is unable to offer any requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 6. Then,schedule the Veteran for VA examination(s) to determine the nature and etiology of his claimed thoracolumbar spine, sciatica, skin, hepatitis C and gastrointestinal disabilities. The examiner(s) should to review the claims file, to include this remand. Following review of the claims file, the examiner(s) should provide an opinion on the following: Hepatitis C (a) Indicate whether the Veteran has a current hepatitis C disability. Please explain why or why not. (b) Is it at least as likely as not that any current hepatitis C disability, is etiologically related to service, to include the Veteran’s reported diagnosis in service and air gun vaccine injections he received during his period of military service? The examiner should specifically address the Veteran’s hepatitis C risk factor questionnaire (if submitted) and any other relevant evidence contained in the claims file in forming this opinion, and fully discuss all modes of transmission. Thoracolumbar spine disability (a) The examiner should identify the Veteran’s currently diagnosed back disability, to include degenerative disc disease. The examiner should reconcile his or her findings with any diagnosis of record. (b) For any diagnosed back disability, the examiner should indicate whether it is at least as likely as not that the disability is caused by or related to service, to include the Veteran’s reports that he injured his back during basic training; he was diagnosed with spondylolisthesis in basic training; while in service he got a congeal bone fragment in his back that sticks in his spine; and his back symptoms have continued to bother him since service. Neurological Disability of the Bilateral Lower Extremities (a) The examiner should identify any currently diagnosed sciatica or related disability. The examiner should reconcile his or her findings with any diagnosis of record. (b) For any diagnosed sciatica or related disability, the examiner should indicate whether it is at least as likely as not that the disability: (1) had its onset in service or is otherwise related to service, to include the Veteran’s reported back injury therein; (2) is proximately due to a back disability, if service-connected; (3) has been aggravated (worsened beyond natural progression) by a back disability, if service-connected. Gastrointestinal disability (a) The examiner should identify any currently diagnosed gastrointestinal disability. The examiner should reconcile his or her findings with any diagnosis of record. (b) For any diagnosed gastrointestinal disability, the examiner should indicate whether it is at least as likely as not that the disability is caused by or related to service, to include the Veteran’s report that he treatment for his upper and lower gastrointestinal disorder during service and got pills for it, that his stomach was bloated with gas and sharp pain and he started bleeding in service, and that he has had reflux issues in his stomach since service. Do not rely on the absence of documented treatment, as that will render the opinion inadequate. Skin disability (a) The examiner should identify the Veteran’s currently diagnosed skin disability, to include vitiligo. The examiner should reconcile his or her findings with any diagnosis of record. (b) For any diagnosed skin disability, the examiner should indicate whether it is at least as likely as not (a probability of 50 percent or greater) that the disability is caused by or related to service, to include the Veteran’s reports of his hair falling off his legs in service because of exposure to leaking ammunitions that had biological and atomical radiation and mustard gas exposure. The examiner(s) is asked to explain the reasons behind any opinions expressed and conclusions reached. If the examiner is unable to offer any requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 7. Then request an addendum medical opinion addressing the etiology of the Veteran’s respiratory disability. The entire claims file should be made available to and be reviewed by the clinician. No examination is necessary, unless the reviewing clinician deems otherwise. The reviewing clinician should specifically respond to the following question: (a) Identify any current respiratory disability diagnoses of record, to include upper respiratory infection and COPD with mild upper and lower fibrosis in the upper and lower lungs. (b) The clinician is asked to state whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s respiratory disability is related to service. The clinician should consider the STR notation of occasional upper respiratory infection in service and the Veteran’s arguments regarding exposure and injury in service and continued symptoms (e.g. that he had respiratory problems, such as upper respiratory infection, pneumonia, and bronchitis in service for the first time in basic training when he was being questioned by his sergeant in the gas chamber for approximately half an hour without a gas mask; that from there, he went to the hospital for an infection and scarring on his lungs; testified that within a couple of months, it was winter, and he got transferred to Germany, where he got diagnosed with pneumonia after being stuck in the snow for 16 hours; that every year around October and November he has a respiratory infection and pneumonia to present; and that he exposed to mustard gas while stationed in Germany related to his job of transporting and retrieving old war heads from bunkers that contained mustard gas and leaked. See October 2019 Board hearing transcript.) The reviewing clinician is asked to explain the reasons behind any opinions expressed and conclusions reached. If the reviewing clinician is unable to offer any requested opinion, it is essential that the clinician offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Schick, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.